Medicaid expansion probably wasn’t in the cards in Missouri before Tuesday’s elections. And now that the Missouri legislature is expected to lurch even further to the right, it appears to be dead on arrival.
Perhaps somewhat surprisingly, however, proponents of expanding Medicaid eligibility haven’t given up hope that health coverage can be extended to thousands of Missourians currently going without.
Although President-elect Donald Trump and the Republican-controlled Congress have made no bones about their desire to repeal and replace the Affordable Care Act, that’s a lot easier said than done.
“To say (Medicaid expansion) is a dead letter may be overstating it,” says Dave Dillon, a spokesman for the Missouri Hospital Association. “It is most likely not going to look like what it looked like under the Affordable Care Act. It may be much more similar to the type of innovative state programs we’ve seen in other states.”
Dillon says that whatever form “repeal and replace” assumes, it could include many of the ACA’s more popular provisions, such as the one barring insurers from denying coverage of pre-existing conditions, “because the ACA was built on fairly conservative principles.”
“It may end up being something like block grants to states for Medicaid,” he says. “It’s going to be very difficult for the leaders nationally to roll back health care that was provided to millions of Americans and hundreds of thousands of Missourians through the health insurance exchange.”
Missouri and neighboring Kansas are among 19 states that have refused to expand Medicaid eligibility. In Missouri, parents with dependent children qualify for Medicaid only if their household income doesn’t exceed 18 percent of the federal poverty level.
Chris Molendorp, a Republican member of the Missouri House from 2009 to 2015 and now a health care lobbyist, was among the few Republicans to buck his party and advocate for expansion during his tenure as a legislator. One of his bills even got voted out of committee, although it never made it to the House floor.
Molendorp is convinced Medicaid expansion in Missouri is going nowhere but, like Dillon, he thinks it’s likely Medicaid will become a block grant program allowing states to write their own rules. And that, he believes, could be a good thing.
“It’s really deeper than whether the Missouri Legislature will expand Medicaid. I think it’s probably more likely that the Legislature will, in the next session or two, rewrite the rules for Medicaid, redesign the program and not just expand eligibility,” he says.
That could mean making eligibility contingent on work requirements or drug testing, or capping the period during which recipients could receive benefits, he says.
“I can’t imagine they’re going to create a program that allows the numbers to grow,” he says, noting that some 920,000 Missourians currently qualify for Medicaid assistance. “What I could envision is a program that would allow more flexibility, that may emphasize preventative care and medical health homes.”
The uncertainty surrounding the ACA’s fate puts at least one hospital – Truman Medical Centers in Kansas City – in a unique position. Truman is the only combined medical, academic and safety net hospital in the state, and it has been a strong proponent of Medicaid expansion.
The hospital provides $100 million of care annually to the uninsured, an amount that would be reduced if more people had health insurance.
Yet Charlie Shields, CEO of the hospital and a former Republican member of the Missouri Senate, doesn’t seem to be particularly perturbed by the prospect of expansion’s looming demise.
In part, that’s because of the significant tax support – accounting for about 9 percent of its net operating revenues – the hospital gets from both Kansas City and Jackson County. And it’s also because Truman benefits from the so-called disproportionate share payments that Medicaid programs pay to hospitals serving large numbers of Medicaid and uninsured individuals.
But Shields also believes that with so much attention now being paid to health care issues, things can’t help but improve in the long run.
“There are a lot of variables in play right now, but I think people are focused on the fact that it’s a big issue in our country, it’s a big issue to our citizens, it’s a big part of our economy, and we probably need to make some changes,” he says. “So I remain hopeful that as the discussion continues, we will make progress in this country.”
Republicans could make good on their threat of getting rid of some provisions of the ACA simply by repealing them through a budget reconciliation bill. Such bills can’t be filibustered. And many of those provisions –the mandate to have health insurance or pay a penalty, for example, or the subsidies, or the requirement that employers provide health benefits – are the ones that make the health insurance market work.
So unless those provisions are retained in any replacement law, it’s not clear where things are headed if the ACA is scrapped. But like Shields, Dillon, of the Missouri Hospital Association, remains surprisingly hopeful.
“We are not in any way completely downcast by what is happening,” he says. “I think there was some degree of bipartisan agreement that certain aspects of the Affordable Care Act needed to be revised.
“If in those revisions that are most likely to happen, including some of the tax provisions that fund it and others, they work to find a better approach to bring those 19 states, including Missouri, into the program, that could be very good.”
Shields points out that some portions of the ACA will be more difficult to repeal than others. And regardless of what happens, he says, Truman will continue to press for greater access to coverage “and to bring our patients into a rational coverage system.”
“We simply believe that people in coverage ultimately are better off from a health care standpoint because they get access to primary care and the things that make a real difference in their lives,” he says.
“So we'll continue to advocate for that. But in the short term, we'll advocate for stable funding for the safety net system. And if we're able to do that, we'll able to continue to provide high-quality for the residents of this community.”
Dan Margolies, editor of the Heartland Health Monitor team, is based at KCUR. You can reach him on Twitter @DanMargolies.